Musculoskeletal
Maria C. Guerrero, DO
Resident physician
Larkin Health System
Miami, Florida, United States
Bendik Stenerson, DO
Resident physician
Larkin Health System
fort lauderdale, Florida, United States
Sahil Shah, DO
Resident Physician
Larkin Community Hospital - Palm Springs
Miami Lakes, Florida, United States
Aagna Patel, DO
Resident physician
Larkin Health System
Miami, Florida, United States
Maria C. Guerrero, DO
Larkin Health System
Miami, Florida, United States
Large spontaneous intramuscular hematoma of the left calf in an elderly patient on antithrombotic therapy, initially presenting as suspected deep vein thrombosis.
Case Description: A 91-year-old female with CHF, PVD, OA, HTN, and CKD was admitted to inpatient rehab after hospitalization for AKI, UTI, and gastroenteritis. On admission, she ambulated 50 feet with a walker and moderate assistance, progressing to 80 feet with minimal assistance. On rehab day 10, she developed acute left lower extremity pain, swelling, and warmth, with sudden inability to stand due to pain. Exam revealed a firm, tender, edematous posterior calf. Duplex ultrasound was negative for DVT x2. The next day, ecchymosis appeared in the posterior popliteal fossa and calf. Labs showed hemoglobin drop from 10.2 to 7.2 g/dL. STAT soft tissue ultrasound revealed a large heterogeneous hypoechoic mass from the popliteal fossa to distal calf, consistent with spontaneous hematoma. She was on aspirin, clopidogrel, and subcutaneous heparin. All antithrombotics were discontinued, and the patient was transferred to acute care for vascular imaging and further management.
Discussions: This case illustrates a rare but clinically significant complication: a spontaneous calf hematoma mimicking DVT in a frail, elderly patient on triple antithrombotic therapy. While leg pain, swelling, and warmth suggest DVT, the absence of trauma and presence of anemia should raise suspicion for alternative diagnoses. In post-acute care, soft tissue hematomas are often overlooked, especially when bleeding risks are underestimated or imaging delayed. The case highlights how non-neurological musculoskeletal events can derail rehabilitation and the importance of interdisciplinary vigilance. Early recognition of red flags—ecchymosis, localized pain, and anemia—is essential to guide imaging and escalation.
Conclusions:
Not all rehab setbacks stem from deconditioning, nor are all swollen limbs due to DVT. As antithrombotic use rises in an aging population, awareness of spontaneous hematomas is essential to prevent delays and optimize recovery.
